Sleep disturbances, such as nightmares and insomnia, are some of the most frequently reported symptoms of posttraumatic stress disorder (PTSD), and they can exacerbate PTSD by interfering with the type of sleep needed for healing. Sleep disturbances also may be resistant to broader PTSD treatments. Data collected from over 4,000 service members indicate that approximately 22% of service members experience frequent nightmares. Additionally, 83% of service members seeking treatment for PTSD report nightmares. And nearly three-quarters of service members report that nightmares persist after treatment for PTSD, warranting specific interventions for nightmares in this population.

Insomnia and nightmares are such a problem in the military that the Department of Defense is disseminating cognitive-behavioral therapy of insomnia (CBT-I) and plans to disseminate a cognitive-behavioral therapy of nightmares called Exposure, Relaxation, and Rescripting Therapy (ERRT). Both treatments have been validated in civilian populations.

CBT-I also has been validated as a therapy in an active duty military population. But there is little research supporting behavioral therapy of nightmares in active duty military personnel, who face numerous circumstances that have a negative impact on sleep. No randomized studies have examined behavioral treatment for nightmares in active duty military personnel.

In order to obtain preliminary data on the efficacy of ERRT in active duty military, STRONG STAR clinical researcher Kristi Pruiksma, PhD, and her research team will conduct a pilot study at the U.S. Army's Fort Hood in Killeen, Texas. The randomized clinical trial will compare a group of 20 Soldiers receiving ERRT with a control group of 20 receiving only minimal contact (MC). The primary aim is to determine if ERRT produces clinically significant decreases in nightmare frequency compared to MC. Secondary aims are to determine the impact of ERRT on nightmare disorder diagnosis, nightmare severity, insomnia, PTSD and depression.

The STRONG STAR-affiliated pilot study will include participants aged 18-65 who have experienced a traumatic event and who meet criteria for Chronic Nightmare Disorder with nightmares that caused awakening at least once per week in the past month. They will be assigned randomly to either five sessions of ERRT or to a five-week period of minimal contact. Participants randomized to MC will later be offered ERRT.

Collaborators include STRONG STAR Director Lt Col Alan Peterson, PhD, (USAF, Retired) of The University of Texas Health Science Center at San Antonio; LT COL Karin Nicholson, MD, chief of Pulmonary and Sleep Services and Medical Director of Respiratory Therapy for the Carl R. Darnall Army Medical Center at Fort Hood; and Daniel J. Taylor, PhD, an associate professor of Psychology and director of Clinical Training at the University of North Texas.

Expected results

This research group hypothesizes that ERRT will result in significant improvements in nightmare frequency and severity, sleep continuity, PTSD and depression compared to the control group. Results will provide useful data for development of clinical treatment guidelines and efforts to address sleep concerns that are highly prevalent in active duty populations and that are related to other indicators of distress, including mental and physical health problems.

This study will yield relevant data needed for larger trials examining physiological changes related to treatment of nightmares, such as changes in sleep stages, and could provide evidence supporting the dissemination of ERRT. It will also help develop the infrastructure for future studies combining ERRT and CBT-I with PTSD treatments in active duty military personnel and veterans.